Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> �l - oi � a3 � <br /> � S <br /> �� p <br /> BUILDING INSPECTION DIVISION . <br /> MSS <br /> 5155 Silverton Rd NE n <br /> Salem OR 97305 ' NOV 10 2021 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.or.us/PWBuildinglnspection 3UILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, cS n , 6v, d r k ,have authorized <br /> (Property Owner/Print Name) <br /> Katie Ryan to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 5 /7 s f S 1r er (5/7 q0 3 i <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: J <br /> Printed Name: 5—Xa.t,.e to, i^ . ors-e�`�� <br /> Signature: ��,G Date: <br /> Address: j9U j /> �'� Phone: <br /> L '1 nQ, n <br /> City, State, Zip j4 n � ./ /r <br /> ' . �- Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company N e: Excavating <br /> Signature: Date: <br /> Address: PO Box 504 Phone: 5f3-743-7343 <br /> City, State, Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address off ice@bethelexc con] <br /> DEQ License# 36198 CCB # -44551 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />